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#18-002722-0062
Supplemental Questionnaire

Last Name
First Name

 

**Please note that your answers on the supplemental questionnaire must correspond to the information provided on your application to receive credit. Applications that do not include a completed supplemental questionnaire will be considered incomplete and may be subject to disapproval.**

 


1.

Do you possess a bachelor’s degree from an accredited college or university in nursing, social work, psychology, education or counseling?

Yes No
2.

If you do not possess a bachelor's degree from an accredited college or university in nursing, social work, psychology, education or counseling, in what field is your degree?

3.

Describe your professional experience in health services.

Please include name of employer, job title, dates of employment, and hours worked per week. This information must also be reflected in your application.  If you do not possess experience in this area, put N/A in the box below.

4.

Do you possess any of the following certifications in lactation management? (Please check all that apply)

International Board Certified Lactation Consultant (IBCLC)
Certified Lactation Consultant (CLC)
Certified Lactation Educator (CLE)
Other lactation management certification
I do not possess a certification in lactation management.
 

If you answered "yes" to the previous question, please submit a copy of your IBCLC license with your application.  You may also indicate your certification number and expiration date below.


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